Managing lower back pain: You may be doing too much
New guidelines call for a measured approach to imaging and medication, while emphasizing psychosocial evaluation.
Of course, you’ll need to rule out potentially serious conditions, such as cancer, vertebral infection, cauda equina syndrome, compression fracture, and ankylosing spondylitis. You’ll also need to check for rapidly progressing or severe neurologic deficits, such as motor deficits at more than one level or a patient’s report of incontinence or bladder dysfunction.
Straight-leg-raise testing and neurologic assessment of the lower extremity—specifically strength and reflex testing of the knee, ankle, foot, and great toe to assess nerve foot level involvement—are key. With this assessment, you should categorize a patient’s LBP as nonspecific, as potentially associated with radiculopathy or spinal stenosis, or as potentially associated with another specific cause (ACP/APS recommendation; strength of recommendation [SOR]: B).1
Pursue imaging—or not? While plain radiography is certainly an option if you suspect a vertebral compression fracture in a high-risk patient, it would not be necessary for a patient like the one in our case. This patient has a classic presentation of acute nonspecific LBP, for which neither routine plain radiography nor advanced imaging (CT or MRI) improves patient outcomes. Given this lack of proven benefit and the unnecessary radiation exposure with certain tests, routine imaging is not recommended for nonspecific LBP (ACP/APS recommendation; SOR: B).1,4-6
Action steps. The evidence supports a number of steps when caring for a patient like the one in our case. Some steps are targeted to patients with nonspecific LBP—and we’ve labeled them as such. Others more broadly apply to patients with LBP.
Explore the possible contribution of psychosocial factors and emotional distress to back pain (ACP/APS recommendation; SOR: B).1 These factors are stronger predictors of low back pain outcomes, including chronic back pain disability, than physical exam findings and duration or severity of pain.7,8 Predictors of poorer outcomes include depression, passive coping strategies, job dissatisfaction, somatization, higher disability levels, and disputed compensation claims. The effectiveness of specific tools for gathering such information has not been demonstrated in the primary care setting. Therefore, fully investigate psychosocial information in the patient interview.
Provide patients with nonspecific LBP with evidence-based information regarding its expected course; advise them to remain active and suggest effective self-care options (ACP/APS recommendation; SOR: B).1 This recommendation is based on findings that the typical course and prognosis of LBP are generally favorable, on studies comparing bed rest versus remaining active, and on outcome studies for self-care interventions.
Self-care includes a variety of interventions patients can implement without a clinical visit—patient education, including self-care books, and patient-structured physical activities. This approach is much less expensive than—and has equivalent or nearly equivalent effectiveness to—costlier interventions such as physical therapy, massage, spinal manipulation, or acupuncture.
Regarding work limitations, there is insufficient evidence for specific guidance. Routinely assess patient age, health, and physical demands and job tasks, and recommend restrictions based on clinical judgment.
Try nonpharmacologic therapies that have proven benefits in the event that self-care fails (ACP/APS recommendation; SOR: B).1 These include spinal manipulation, defined as manual therapy in which loads are applied to the spine by using short- or long-lever methods and high-velocity thrusts are applied to a spinal joint beyond its restricted range of motion. Serious adverse events are extremely rare.3
If medication is needed for acute LBP, first-line drugs include nonopioids with proven benefits, such as acetaminophen, nonsteroidal anti-inflammatory agents, or skeletal muscle relaxants (ACP/APS recommendation; SOR: B).2
CASE 1
The patient’s course
The physician carefully reviews the 32-year-old patient’s psychosocial factors and finds that he is positive about his job, enjoys his work, and is not seeking compensation. He uses exercise and prayer to manage stress and is in a stable relationship. He does not smoke, use recreational drugs, or have a history of psychiatric disorders, including depression. He says he drinks 2 to 3 beers on the weekends.
In discussing treatment, the patient considers PT as the optimal intervention. His doctor does not recommend it, and instead encourages him to remain active, gives him a self-care booklet on stretching and exercises, and advises him to check in again as needed, reassuring him that most cases of nonspecific acute low back pain resolve spontaneously.
Initially the patient does well with self-care and he returns to activity. However, 6 weeks after his office visit, the patient returns with pain that has worsened over the last 2 weeks. He has also begun experiencing tingling sensations down his right leg, trouble standing for short intervals because of pain, and weakness in his back. On physical exam, he still has minimal tenderness to palpation over the right lumbar region. The right straight-leg-raise test yields a positive result, and the right patellar reflex is diminished compared with the left. His rectal tone is normal. His gait is antalgic.
